ASSESSMENT of the TRAINING of the FIRST INTAKE OF HEALTH

EXTENSION WORKERS1

Yayehyirad Kitaw, Yemane Ye-Ebiyo, Amir Said, Hailay Desta, Awash Tekelhaimanot
Abstract
Introduction Ethiopia is suffering from a health crisis due primarily to communicable diseases, poor
nutrition, and lack of access to health services in general, and for most of the rural, nomadic
pastoralist and fringe areas in particular. Recent initiatives (Millennium Development Goals,
Sustainable Development and Poverty Reduction Program etc) have amplified the underlying
human resources for health (HRH) crisis. In response, the government has launched a Health
Services Extension Program (HSEP) for which training of Health Extension Workers (HEW) has
been started. This study assesses the first year’s HEW training program in terms of its inputs,
processes and impact.
The Method of the study included a questionnaire survey and an in-depth study of all the training
centers except one.
Results All the Technical and Vocational Education and Training Institutes (TVETIs) studied
were found to lack adequate facilities to receive the HEW trainees including classrooms, libraries
ICT, water and latrines. The selection of HEW was flawed, most being from woreda towns and
not the rural villages they will be working in. Most trainees had very low grade point average.
Trainees did not have adequate orientation on their future job at recruitment. Trainees in Tigray
and Amhara did not receive stipends contrary to those in Oromia and SNNP. However, trainees
expressed a high level of commitment to work in rural areas. The number of trainers was low and
very few were female or with degree. Top-up of salaries were given in some regions but not
others and trainers saw their employment status as ambiguous. Teaching and learning conditions
were constrained with very little practical training. The apprenticeship program was deficient in
spite of an extension by one month.
Conclusion Major issues are discussed and recommendations made on improving future training,
improving the knowledge and skill of graduates through continuing education and on future
training to replace attrition.

1. Introduction
Ethiopia is suffering from a health crisis due primarily to communicable diseases, poor nutrition, and
lack of access to health services (1). Since 47 percent of the population lives below the poverty line
and income per capita is only around USD 100, most people cannot afford health care, and
consequently the average life span remains only 46 years. The main 'modern' health care provider
is the government, which manages most of the country’s 5,873 Health Station/Health Posts, 600
HCs and 131 hospitals (2).
Modern health services only cover about 60% of the population, with little access for most of the
rural, nomadic pastoralist and fringe areas. Even these limited services are underutilized due to
economic and social barriers. The low rate of health care utilization is indicated in the fact that
only 30% of pregnant women receive antenatal care and only 10% are attended by a health
professional during delivery (2, 3). Recent initiatives (Millennium Development Goals,
Sustainable Development and Poverty Reduction Program etc) have accelerated the anticipations
in development and the related requirements to upscale health services have amplified the
underlying human resources for health (HRH) crisis.
In response to the country’s health crisis, the government introduced in 2003 the Health Extension
Program (HEP) as part of the primary health care service (4). The HEP is an innovative health
1
Center for National Health Development-Ethiopia. Correspondence <yayehyirad@ethionet.et>. Based on
report communicated to major stakeholders in 2005; a number of measures on issues raised in the report
have been taken by the concerned authorities.

1
service delivery program that aims for universal coverage of primary health care by 2009. It will
place two government-salaried female HEWs in every kebele, with the aim of radically shifting
the emphasis of the country’s healthcare system to prevention and improve the uneven resource
distribution. The magnitude of the effort that is being undertaken can be best appreciated by
noting that the number of new health service staff positions that will be created under HEP in less
than five years is more than double the number that that was created in the previous more than 5
decades (5).
Training of 2,400 HEWs was completed by the end of 2004in 11 Technical and Vocational
Institututes/Centers; 7,000 HEWs were in training in 2005 and a total of 30,000 HEWs will be
trained by 2009. Thousands of other health care services staff, particularly at the HC level, will
receive training to aid in the accelerated implementation of the HEP (6).
The Technical and Vocational Education (TVE) program in the country is based on a major,
multi-billion birr government initiative for capacity building, spearheaded by a high level
Capacity Building Coordinating Committee chaired by the Prime Minster established in the late
1990s. A sub-committee on technical and vocational training and education chaired by the
Minster of Commerce and Industry was established in 1991 EC (1998/9 GC) with MOH as one of
its members. The HEW Training Program is modeled on industrial TVE. The training course is,
therefore, geared primarily towards practical work and apprenticeship (7,8).
The curriculum and teaching materials have been developed on the basis of limited experience
from the pilot projects carried out in one region and inputs from similar programs carried out in
other countries (7,8). As any new program, it is bound to face challenges because “well-
established programmes are usually assumed to be ‘good’ until proved otherwise, whereas
innovative programmes are assumed to be ‘poor until it is proved otherwise” (9).
The experiences from this first training can provide important information which can be used to
develop and refine the program for future years. It is essential that a rigorous, professional
assessment of the current program is undertaken in order to draw lessons for the future.
The objective of the study was to assess the first year’s HEW training program in terms of its
inputs, processes and impact in order to recommend improvements for subsequent trainings.
Specifically, issues related to recruitment process and outcomes; adequacy of the curriculum ;
quality of the training process; perception of trainees, trainers and other stakeholders; and needs
for continuing education were assessed.

2. Methods
The Center for National Health and Development in Ethiopia (CNHDE) undertook the
assessment in 2004. A former member of the Education Faculty at Addis Ababa University, with
expertise in training evaluation, (now on UNESCO assignment in MOE) provided expertise in
educational planning and evaluation. The staff of the CNHDE developed the assessment
methodology based on previous experiences in Ethiopia (10, 11, 12, 13, 14, 15) and abroad (16,
17, 18) of which the following were the main components:
 Questionnaire survey to assess the opinions of students, trainers and status of facilities on
various aspects of the training program
 In-depth study of the training centers
CNHDE staff members carried out the in-depth and on-site assessments of all the training centers
operational for the 1st intake (except the training center in Mettu). Assessments were undertaken
through visits, interviews, observations and group discussions. In addition, discussions were held
with area health service offices including RHB, WHO, HC, and the Woreda administration.
Instruments developed for the questionnaire assessment were adapted for use in interviews with
health service offices.
 Feedback and dissemination of findings
Assessment findings will be disseminated to parties involved with the training to ensure that
appropriate follow up is undertaken.

2
3. Results

All the Technical and Vocational Education and Training Institutes (TVETIs) studied were found
to lack adequate facilities to receive the HEW trainees (Table 1). They did not have enough time
or information to prepare the facilities. For example, the Director of Assela TVETI was told, in
August 2003, to prepare 3 classrooms for HEW without any additional information. In Nov.
2003, students start arriving, but there were no trainers and no material (Students refuse to return
to woredas).Orientation meeting for all directors was held by MOH in mid-December with
promises to solve outstanding problems. Thus training started bur there was no budget even for
salaries for three more months.
Organizational arrangements varied from one institution to the other, but often the HEW trainees
were perceived as being completely external to the institution.
Classrooms were inadequate in almost all centers. Most used classrooms prepared for elementary
or secondary school students. In Butajira, classes were taught in temporary corrugated iron
structures. Even though the HEP Implementation Guidelines indicated that there should be 20-30
HEW trainees per classroom, TVETIs were asked to provide one room for 50 trainees, and most
had much higher number of trainees per room (Table 1). Only Dilla had what could be considered
adequate conditions in terms of trainees per room. Often, trainees were so crowded they had
problems taking notes. In a class room in Mekelle, students were seated four to a desk, which was
designed for three children, and were hardly able take notes. An extreme example is Axum,
where there were enough chairs and desks for only half the trainees, which meant that half of the
class had to sit on the floor or on makeshift arrangements (such as stone slabs, etc.).
Libraries were almost nonexistent for the first intake of HEW in all TVETIs (Table 1). Some had
rooms, but none had books relevant to HEW training. Those with libraries had few books on
other vocational subjects, and reading material was generally out of date. Recently some HEW-
relevant books (modules, books prepared for health officers, nurses, etc.) have been received but
most training centers had not yet worked out the modalities of their utilization as the contents and
numbers of copies vary from less than 10 to over 200.
Facilities for Information and Communication Technology (ICT) are inadequate. Some centers
(5 of the 10) have a few computers for the regular TV trainees (Table 4.1), but even there the
number of computers was inadequate.

Table 1: Training of the First Intake of HEW: State of Training Facilities, 2004
TVETI No. Class-room Library ICT (PC) Water Demo Practice
Student (capacity) /latrine Room Site
Axum 200 4 -- -- ? -- ±
Mekele 197 4 ± -- ?? -- ±
Dessie 396 8 45 25 ++ -- ±
D/ Marcos 323 6 -- -- ± ? ±
Assela 154 3 50 -- ± 50- ±
Fiche 150 6 -- 15- ±
Goba 153 3 100 26 ++ (2)40- ±
Shashemene 146 3 40 34 # ±
Butajira 375 6 S 45 ± # ±
Dilla 375 13 S 39 ++ # ±
-- Do not exist, ? Almost inexistent, ± Exists but dubious functionality, # Under preparation, S
Small, ++ Adequate

Most trainees had only lectures on ICT and never used a computer. Sometimes, lack of access to

3
PC resulted from TV staff being unwilling to allow HEW trainees to use the facilities. For
example, in Dessie, there was an ICT room with 45 PCs, however, there were conflicting report
between the TVETI staff and HEW trainers on whether HEWs had access to them.
Water and latrines were inadequate in almost all TVETI except Dessie and Dilla. In addition,
most of the toilet facilities were very unsanitary. In some centers such as Mekele, we were
persuaded not to visit them. The TVETI in Axum was judged to be in the worst condition.

The selection criteria for HEW trainees varied slightly from document to document (7, 19) and
between regions. However, of the core criteria, only sex, all female, and completion of 10th grade
of general education were fully adhered to. In fact, quite a high number have completed 12 th
grade and there were also a large number of trainees who have been out of school for many years
and had difficulty in following the training program.
An important criterion, being ‘From the kebele of future assignment (or neighboring kebele or
woreda)’, was not adhered to in most cases as very few HEW trainees were recruited from the
kebele proper. A large number were from towns because of flaws in the selection process.
Recruitment for Mekele, for example, was done through advertisement in schools, which meant
that most recruits are from towns and particularly from towns where there are TVETIs.
The selection process as a rule was supposed to start at the kebele level. In practice, at least for
the first intake, trainee selection was carried out primarily by the Woreda Committee chaired by
Capacity Building with the WHOs and WEO as members. Although WHOs have membership on
the Woreda Committee, most of the WHOs expressed that they were excluded from involvement
in the final decisions. Trainees were recruited mostly from woreda towns, which was prompted
essentially by the high number of unemployed youth in these towns.
Speaking the language of the community/region seems to be presumed in most regions; only
SNNP had ‘speak the language of the kebele’ as explicit criteria. However, ensuring that these
criteria are met during the HEWs’ assignment will not be an easy task since most trainees have
been recruited from urban areas.
Other criteria: (mentally/physically sound, active participant, etc): There was no age limit so
some trainees over age 30 have been recruited. This had led to a number of difficulties in training
as some have children and other family responsibilities. The mentally and physically sound
criteria were not rigorously applied as there was, in most cases, no medical check-up
consequently there were a number of handicapped and pregnant women. This has impacted on the
learning process and is bound to impact on future assignment.
Low Grade Point Average: According the HEP Implementation Guidelines, the minimum GPA
required for admission is 1.2, in order to get students from the rural kebele level. The pool of
potential applicants (females possessing an education of grade 10 th to 12th grade) is very large.
However, all reported that the HEW training program has not attracted the better students. This,
coupled with the fact that most of these have been out of school for a long time, has created
difficulties in following the courses.
Orientation was inadequate. Most trainees seem to consider being a HEW as only a stepping
stone to becoming a nurse. Some of them claim that they have been promised as such during
orientation. However, all have been clearly informed that they will be working in rural kebeles
and have, except in Tigray, signed agreements to serve in kebeles.
No stipend is provided to trainees in Tigray and Amhara. Most trainees are said to be from poor
families. Families reportedly had to sell oxen or whatever valuables they have to pay for their
training. Most find it difficult to meet the requirements for the whole year. As no support is given
(dormitory, food or cash) by the government and living expenses (such as house/room rent and
cost of food) are high in the big towns, most trainees find it difficult to cope. In Dessie for
example, a number of them were forced to do odd jobs, mostly at night, to meet costs; a number
go hungry to classes and have difficulties following the program. On the other hand, Oromia
gives B135 per month and SNNP gives B200 per month, which greatly reduces these hardships.

4
The provision of stipends is apparently a well-established practice in teacher training.
Trainees express high commitment and willingness to work in rural areas. Attrition (about 1%)
was low. Most say they are committed to work in kebeles and change the life of villagers. Even
trainees who were recruited from the towns believe they can adapt easily to rural community life,
as most have moved to towns only recently.
All trainers were full-time, mostly sanitarians (43%) and public health nurses (41%). There were
very few female trainers (11%) or degree holders (6%). In most centers there is a home-science
teacher, who covers the nutrition and related subjects. On average, there were 37 trainees per trainer
(Table 2).

Table 2: Training of the First Intake of HEW: Number of Trainers by Qualification,

2004
TVETI Student HO PHN Sanitarian Other Total Notes
☥ º
Axum 200 1 1 2 - 4 1 1
Mekele 197 1 1 2 - 4 1 1
Dessie 396 - 5 5 1 11 1 0
D Marcos 323 - 6 7 1 14 1 1
Assela 154 - 2 2 1 5 - -
Fiche 150 - 2 2 1 5 0 0
Goba 153 - 2 2 1 5 0 0
Shashemene 146 3 3 1 7 - -
Butajira 349 2 2 1 5 1 0
Dilla 349 3 3 6 2 1
☥Female, ºDegree holder, HO Health Officer, PHN Public Health Nurse

Amhara and SNNP do not give any salary top-up to trainers while Oromia and Tigray provide
300 Birr per month. This varying top-up policy has led to resentment among the trainers in
Amhara and SNNP as they are well aware of the practices in the other regions. They have
repeatedly petitioned the TVE Commission, and trainers from Dessie and Butajirra have gone on
strike in protest of this and other issues.
Trainers view their employment status as ambiguous. Except for Tigray, they have been transferred
to the education sector. This means that they were no longer in the government health sector’s
employment structure and were not considered for staff benefits such as in-service training,
upgrading, and free medical treatment. Trainers stated that they felt that they were being bypassed
for these opportunities – only two participated in short workshops during the year.
On the other hand, trainers do not seem to be included in the employment structure of the
Technical and Vocational Education and Training Commission. Since the HEW trainer position is
considered a temporary assignment, they do not know how they will fare after the training
‘campaign’ is over after 3-4 years. In general, they feel caught between TVE Commission and
RHB and are apprehensive about the future. Due to this uncertainty, there is tension between
trainers and management in almost all TVETI. As noted above, during our assessment, the
trainers in Dessie and Butajira were on or returning from strikes.
There is a high degree of commitment among the trainers in spite of the problems cited above.
All understand clearly the policy and implementation principles of the HEP and seem quite
committed to it despite implementation problems and their own grievances. All trainers
underwent a one-month TOT (training of trainers) program organized by the FMOH
All trainers appreciate the TOT training methodology. They believe that the TOT was good in
preparing them for their tasks, but all groups independently stated that the training would have
been more effective if it had been given by Ethiopians who would have been more sensitive to

5
issues in the cultural context. There also seems to have been some language problems during the
TOT.

There was no proper planning of the training process at the institute level. Programming seems
to have been left to the discretion of the trainers themselves as the curriculum guide provides only
a very general sense of the sequencing of the courses. Their limited number, limited training
experience and the fact that they have to depend on others for all the common courses and most
of the supportive courses has made course programming a difficult task for trainers. They have no
guidelines on registration of students, sequencing the courses, on practicals, on the apprenticeship
program, etc.
The situation in Mekele is a good illustration. As the coordinator for the second intake said, "We
[the trainers] have worked out our plans but those who direct the program have no plan." The
common courses, which should have been given prior to starting the other courses have not been
started because of apparent budgetary constraints (the TVETI staff would have to be paid), or
because there are not enough TVETI teachers. In Butajira, they are trying what they call a ‘self-
contained’ method in which a trainer handles all the main courses for a class of trainees.
English as language of instruction has proved problematic. Most trainees were clearly not able to
follow the course in English due to their limited use of this language, poor educational
background and/or the fact that they have been out of school for many years. A large number
were unable to understand standard written text in English. The usual practice was for the trainer
to write the text on the black board in English for students to copy; otherwise explanations (and
discussion if any) were carried out in Amharic or the regional language. Both trainees and
trainers emphatically suggested that the courses should be given in the local language.
The first intake of trainees had no books of any kind. Single copies of the modules were available
only for the trainers. In some TVETI the staff duplicated their notes for distribution but these
were often limited in number due to a lack of paper, etc. Most trainees left the centers with the
notes copied from the blackboards alone.
The curriculum prescribed 70% practical training but, in almost all cases, there were no facilities
(demonstration room or models, health services near by etc) for practical training; therefore
nearly all the courses were 95% theory. Some TVETIs had assigned rooms for demonstration
(e.g. Asela, Goba had two rooms as shown in Table 1) but none had demonstration materials. In
some cases, (e.g. Debre Marcos and Dilla) the trainers and trainees have tried to build their own
models from local materials. A few institutions (e.g. Mekele and Butajira) borrowed
demonstration materials from nearby health professional training facilities. The curriculum
includes ICT (information communication technology) but few TVETI had adequate IT rooms
and most trainees had only theory-based lessons. The few trainees that had actually touched or
seen computers had only very limited exposure.
In most cases apprenticeships were arranged at the eleventh hour. Issues of whether HEWs
would undertake field placements in HCs or even hospitals were not resolved until the last
minute. Supervision and responsibilities were not clearly defined and therefore the trainees did
not have enough exposure to procedures they were supposed to carry out. To remedy this
situation, an additional month of a better organized apprenticeship was carried out in all regions
except Oromia. These supplementary apprenticeships were of markedly better quality, but were
still carried out with a great deal of uncertainty.
The experience from Dessie provides a typical illustration of problems with the apprenticeship
program for the first intake of trainees. In Dessie, students were assigned to HC and HP in nine
woredas for their apprenticeship. Work assignment and supervision was assumed to be given by
health workers at service delivery points (SDP) who were supposed to be given orientation on
HEP. In most cases, the health workers had little idea of what HEP was or what was expected of
them during the apprenticeship. Consequently, a number of trainees wasted almost a month
before doing any practical work and others spent most of their time in the outpatient department

6
(OPD) and almost no community work. Some HEWs were, supposedly, 'supervised' by frontline
health workers (FLW).
The trainers were not involved in supervision because it was assumed that the professionals in the
service delivery points could provide adequate supervision and guidance. Later assessment
showed major deficiencies, and it was decided to extend the apprenticeship by a month. However,
shortcomings such as lack of adequate exposure and practice in injections (vaccinations, family
planning) and in assisting delivery of infants persisted.
The apprenticeship was carried out either during the meher harvest period (Amhara and Tigray)
or the rainy season (SNNP) hampering access to the villagers. In Mekele and Axum for example,
students were sent for their apprenticeship at the height of the harvesting period. Many
households left very early in the morning for the fields and came back very late. It was therefore
very difficult for the trainees to work with them for planned activities. Trainees had to go to the
households at five o'clock a.m. in order to meet them before they left for the fields.
In some regions (e.g. Tigray) there was no plan for a uniform. In others (e.g. Amhara), white
gowns were ordered at the end of the training period but had not yet been distributed to trainees.
In clinical contexts, (the HC, for example) trainees were difficult to distinguish from clients.
The first intake was not budgeted, but rather relied on extra-budgetary allocations and, in a
number of cases, on subsidies from the TVETIs. The health professionals continued to draw their
salary mostly from the health sector (their previous place of employment).
It was difficult to get a complete picture of the operational budget of the training program
because TVETIs varied in their use of common utilities and resources from other governmental
departments. However, it is considered inadequate (Table 3). In fact, most TVETIs had to
subsidize the HEW training from their internal income. For example in Dessie each student was
allocated Birr133.8, but the estimated cost of the training per student was Birr353.5 – the balance
was subsidized from the TVETI’s internal income.

Table 3: Training of the First Intake of HEW: Budget by Institution 2004

TVETI Student Salary& Operational Total Per Student

Allowance (total/operational)
Axum 200 RHB 50,000 /250
Mekele 197 RHB NK NK -
Dessie 396 149,232 53,000 202,232 511/134
D Marcos 323 - 30,478 - /94
Assela 154 271,960 11,300 283,260 1839/73
Fiche 150 - - - -
Goba 153 41,700 - - (273)
Shashemene 146 333,360 - - (2283)
Butajira 375 900,000 100,000 1,000,000 2667/267
Dilla 375 954,180 77,500 1,031,680 2751/207

Future plans
At the time of this study, the training institutions had just taken or were preparing to take the
second intake of trainees. Woredas were anticipating the deployment of the first group of HEWs

7
in the field. It was therefore important to know the level of planning and readiness at the different
levels of the health sector for HEW deployment, particularly at the level of the Woreda Health
Office (WHOs).
The institutes were not given ample time to do pre-planning to accommodate the HEWs training.
There was still ambiguity on the sense of ownership of HEP by TVETIs, as well as the ad hoc
relationship between the RHB and TVE Commission.
Woredas seemed to be well acquainted with HEP but there was a tendency, even in a 3-man
WHOs, to leave HEP to the focal person. Information and sensitization of kebeles before the
assignment of HEW both during apprenticeship and their final assignment was deficient.
All woredas visited had only budgeted for the salary of HEW at least for the remaining months
of the fiscal year. There seemed to be little awareness/concern for operational budget.
Preparations for supervision were limited. Most woredas were seriously understaffed,
operational budget were restrained, and many lacked adequate vehicles. Our visit and interviews
indicate that WHO officials and HC heads envisage direct and substantial involvement of the HC.
The trainees spontaneously raised the issue of upgrading training and hinted they have been
promised that they will be given priority for upgrading training to nursing. They also stress the
need and importance of continuing education and anticipate its early implementation.
Once the campaign training is completed, there will be need to plan for future replacement
training of HEW. Future training will be needed to fill HEW posts created by attrition, the
creation of new kebeles and the upgrading of a certain number of HEW. After a few years some
2500 to 3,000 will have to be trained annually.

DISCUSSION AND CONCLUSIONS

The HEW training is a new venture and, as should be expected of any new undertaking, has its
birth pangs and transition problems. The challenge is to constructively appraise the program to
date and draw lessons from its strengths and weaknesses.
The most encouraging aspect of the program is that most trainees seem genuinely positively
disposed towards their eventual assignment in spite of not being recruited from rural kebeles and
the hard conditions (specially those in Amhara and Tigray) under which they have trained. The
same disposition was noted for mid-level trainees earlier (20). The trainers are confident in their
training ability, have positive attitude to HEP in general and to the training program in particular.
The TVE institutes have provided classrooms and a number of other resources (library, staff
room) from their very often limited resources. Most have also subsidized the budget of the HEW
training from internal income by other departments. This is certainly an important indication of
ownership and commitment to the program and has permitted the program traverse some critical
moments (e.g. lack of demonstration materials). The support in giving the common courses and
some of the supportive courses has also been critical. The Institutes with their large faculty also
present the potential for wider professional interaction between staff (unfortunately not fully
exploited because the HEW staffs are over burdened).
All TVETIs were already working under financial, human resource and infrastructural constraints
for their regular programs; the addition of HEW trainees exacerbated these problems. All
facilities – classrooms, libraries etc were inadequate in almost all TVETIs. In most institutions,
the toilet facilities were in poor and often unusable conditions. These unsanitary conditions
should not be tolerated by HEW trainers and trainees, especially since they are expected to
promote better environmental conditions in rural areas.
The selection process was dominated by the Technical and Vocational Education (TVE) sector
with minimal involvement of the health sector. Most trainees were selected from woreda towns
(not rural kebeles) and this could have a distorting effect in the future development of the HEP.
Another major weakness is that the program seems to have attracted trainees with much lower
grades compared, for example, to those in the regular TVE programs. One reason was that

8
recruitment of the first intake started late and the better students were already enrolled in the
other fields. In other cases, the potential trainees seem to prefer other areas such as education.
Stipends may be a factor in the preference of potential applicants to other fields. Other factors
need to be explored since the trend of attracting less qualified applicants has continued for the
second intake.
Regarding trainers, the curriculum guidelines (8) specify that “For the training programme, the
principal facilitator must be Bsc (sic) Nurse and she or he will be assisted by Bsc/diploma nurses.
Preference will be given to those with managerial and teaching skills. Diploma nurses or
sanitarians (sic) will be posted as instructors in demonstration rooms, clinics, health centres and
at kebeles. Each training programme will have a minimum of two full time facilitators.”
These guidelines do not provide a clear picture of the number or types of trainers needed in the
classroom, and therefore are not clear regarding the number of trainers required. The above
statement seems to imply that there should be as many trainers as demonstration rooms, clinics,
etc. The TV Strategy (7) also indicates that trainers should have a minimum of diploma-level
training.
In most cases, the trainers are too few in numbers and therefore are overloaded. In Oromia the
ratio of trainees to trainers was relatively good (30:1), where as in Tigray and SNNP the ratios were
50:1 or even higher. It is clear that when the ratio of trainers to trainees is very high, trainers cannot
interact sufficiently with individual trainees nor adequately guide their development. Trainers
complained that they could hardly recognize the students let alone monitor their development.
Most teach 7-8 hours a day, often on subjects for which they feel ill-prepared. They could not
conduct small group activities such as group discussions, role play, etc. Their limited number also
makes supervision during practical and apprenticeship very difficult. For an All-female student body,
the number of female trainers was very low.
For trainers, uncertainty about the future is one of the most critical problems of the program. They
feel insecure about their status as they feel lost between the TVE and the health sectors.
The teaching/learning process suffers from the lack of textbooks, reference materials,
inadequate practical/demonstration facilities and a compromised apprenticeship program in spite
of last minute remedial efforts.
There are no detailed guidelines on programming the courses which is left to ill-prepared trainers.
In these conditions, local initiatives, such as the self-contained method in Butajira would not have
sign-posts against which to check. While this approach may have some merits, it may also detract
from the quality of instructions in a number of fields, which require experience and expertise. In
practice, this approach has meant that instructors are teaching outside their area of expertise, such
as a public health nurse teaching and giving practicals on sanitation or an environmental health
technician teaching family health.
The first HEW graduates will be going to their kebeles virtually without any reference materials
except their own notes. It is clear that they will be faced with a number of challenges and issues
not addressed or adequately articulated during their training. It is therefore important to provide
the HPs with simple, practical reference materials in the most important fields preferably in the
local language or in Amharic. The MOH has printed the modules and some additional materials
both in Amharic and English. It has also developed, through the Carter Center, in association with
MOE and USAID a series of ‘Lecture Notes for Health Extension Trainees in Ethiopia.’ The
RHB in Tigray is translating the modules and intends to distribute them to HPs as soon as
possible. These are commendable undertakings that should be emulated by other stakeholders. It
is now important to get these materials in the hands of HEW as soon as possible. Understandably,
most of these materials have been prepared in haste and need to be evaluated and improved upon.
For example, though the Lecture Series contains valuable material, it was prepared by
university/college instructors with little exposure to HEP. In addition to the use of English, it is
doubtful that the content of some of the subjects could be effectively understood by HEWs.
The operational budget for HEW training was clearly inadequate. HEW training programs were,

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as most TV training programs in general (19,20), under-resourced. In this situation, it would seem
logical to try as much as possible to mobilize local resources to support the program. All HEW
training TVETIs are located in relatively large towns with a number of government and NGO
institutions, including RHB, health professional training facilities, hospitals, HCs, etc. These
institutions could be approached for support in terms of teaching staff, demonstration materials,
etc. (e.g. Butajira and Mekele have used demonstration materials from nursing schools).
Presumably the staff of these institutions is already heavily burdened, and the budgets of the
TVETI may not be adequate to cover the additional costs of using these staff. Nevertheless, ways
of deriving support from these institutions should be proactively sought.
The issue of uniforms for trainees and eventually HEWs needs to be clarified.
The Future
The first group of HEWs is being deployed but WHOs and Health Centers in woredas seem ill-
prepared to receive and put them effectively to work. Most WHOs do not have adequate staff and
budget to ensure proper supervision and support. Only salaries of HEW have been budgeted with
no provision for operational expenses for HEP and the additional tasks of WHOs related to the
HEP. Community mobilization in support of HEP has hardly started.
Financial support to HEW activities should be seriously considered and explicitly addressed. HEP
is bound to impact significantly on the WHOs’ operational budget (for logistic support,
supportive supervision, etc.) but little thought and preparation seems to have been given to the
issue. Given the general budgetary constraints, the program could suffer unless conscious
measures are taken urgently both for improved operational budget for WHOs and operational
budgets for HPs. If extra-budgetary resources (community contribution, donations, etc.) are
envisaged, it must be made explicitly known to all concerned, and sensitization and mobilization
of such resources should be started well ahead of the deployment of the HEWs.
As duly stressed in the HEP Implementation Guideline (21) supervision is key to the success of
community-based public health program as shown by experience (CHA, TBA, CBRHA, etc. see
also 22, 23). From our visits and interviews, however, it is clear that the conditions are far from
adequate. It is also one of the weak points of the Ethiopian health system (24). There seems to be
ambivalence on the nature and magnitude of the involvement of the HC in the supervision of
HEWs. Though they have the same constraints as WHOs, HCs constitute significant additional
resource in support of HEW both in terms of technical human resource as well as logistic support.
However, mixed signals are being sent from the regional and federal level on whether they will
participate in the program, and on the nature of their participation.
Continuing education (CE) is critical to the success of HEP. New developments are bound to
come (the role of HEW in ART, the introduction of HEW to stronger tools for community
mobilization such as Community Conversations now being adopted by HAPCO, new
developments in malaria, the requirements of the New Global Child Survival Partnership, etc).
There is a need, therefore, for continuing education as well as remedial measures for some of the
deficiencies in pre-service training. The MOE TVE Strategy (7) clearly mandates tracer studies in
order to take remedial steps. Continuing education is also necessary for the trainers to keep up
with developments. As one of the trainers (Dessie) said, "I hear that there is a change in the drug
for malaria but I do not even know its name."
Little thought seems to have been given to plan for future replacement training of HEW. Future
training will be needed to fill HEW posts created by attrition and the creation of new kebeles.
This will be a new venture and will have to be well thought through to live up to the HEP
expectations. There are very few data on attrition in public health services in Ethiopia (24). Kinde
and Kenso (25) estimated the attrition rate at 10% “based on empirical wisdom”. They showed
that attrition was highest for the most peripherial (rural) facilities. A recent study (26) uses a high
9.6% for MD and a low 3.2% for nurses. Based upon these experiences, an attrition rate of 5-7%
per year (due to marriage, movement into the private/NGO sector, etc.…) could be expected for
HEW. Assuming that another 5% of HEWs per year will aspire to upgrading their education and

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professional status after a few years, some 2500-3000 would have to be trained each year.
There are a number of questions pertinent to recruiting and training replacement HEWs,
including: How are their replacements to be selected; from which kebeles? Who should run the
training program? Should not the health sector play the leading role, as mandated by the TVE
Strategy (7), to avoid some of the shortcomings of the current arrangements? Where will they be
trained? The RHB in Tigray is envisaging their training in nursing schools. The strong points for
this arrangement are not difficult to see but are they the best place for HEW training focused on
prevention and control? Could the numbers involved, at least in the big regions, warrant a
dedicated school/training center(s)?

It is recommended to start recruitment as early as feasible so as to attract better GPA; give clear
guidelines on selection; make sure it starts at kebele level and make it as participatory and
transparent as possible. The number of trainers should be increased (by at least 50%, with one or
two at degree level) and their employment status (duties and privileges) should be clarified.
Textbooks should be provided to trainees as soon as possible. Start at least with the modules in
Amharic. Each HP (HEP) should have at least one copy. Eventually, study, prepare and distribute
the modules and other reference materials in other languages. Demonstration rooms with
adequate teaching aids should be organized. The apprenticeship program should be better design
and organized to ensure ways for more active involvement of the trainers, WHO & HC in
supervision.
In preparing the future working conditions of HEW, WHOs and HP operational budgets should
be increased; HEP operational plans including cost (supervision, logistics etc) at the WHOs level
clearly worked out; plans for the remedial/continuing education of HEW prepared; and the
possibility of introducing stipend for trainees and top-up for trainers explored.

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Acknowledgement
The logistic support and overall cooperation of the MOH, RHBs and WHOs is highly
appreciated.

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